Sales Operation Administrator

• Aug 2020 - Present

Medical | Workers' Compensation Claims Specialist | Customer Service

• 1995 - Jun 2020

I have extensive knowledge of medical claims processing, including medical terminology, appropriate medical treatments, and medical record review. I am currently seeking new opportunities in Northeast Ohio or Work From Home arrangements. I can be contacted via LinkedIn or at susanejakubowski@gmail.com I have extensive knowledge of medical claims processing, including medical terminology, appropriate medical treatments, and medical record review. I am currently seeking new opportunities in Northeast Ohio or Work From Home arrangements. I can be contacted via LinkedIn or at susanejakubowski@gmail.com

Medical Claims Specialist

• 1995 - 2020

Medical Only Claims Specialist, Workers’ Compensation | 2002 to 2020Investigated Workers’ Compensation (medical only) claims. Verified coverage, set reserves, directed medical treatment where appropriate, and contacted employers, injured workers, and medical providers. Reviewed medical notes and bills for medical necessity, relatedness and approved for payment. • Processed Workers’ Compensation claims across jurisdictions, including Florida, Kentucky, Minnesota, Arizona, South Dakota, Iowa, Georgia, and Alabama. Managed up to 160 pending claims, from simple to complex.• Investigated the facts of injury, compensability/liability/negligence determination, coordination of medical care, and damage assessment. Documented facts of loss and pertinent claims facts such as employment, wages, or damages.• Contacted the Employer, Employees and Medical Providers to determine liability, compensability, negligence, and subrogation potential. Obtained needed information and explained benefits, with the goal of providing excellent customer service. • Established appropriate reserves with documented rationale, maintained, and adjusted reserves over the life of the claim to reflect changes in exposure, and established disability with treating physicians. • Ensured timely denial or payment of benefits in accordance with jurisdictional requirements, corporate client claims handling guidelines, and industry best practices. Recognized and reported potential fraud cases.• Established and implemented appropriate action plans for case resolution, including medical and disability management, litigation management, negotiation, and disposition.• Reviewed medical bills for appropriateness, payment, and approval. • Participated in a cross-functional Medical Bill Review cost containment program.• Assigned as Subject Matter Expert to review medical bill reviews in collaboration with Genex (3rd party medical review processor). Show less

Supervisor, Claims Files

• 1999 - 2002

Administrative Assistant, Claims Department

• 1995 - 1999

Administrative Assistant - Tank Department

• 1992 - 1995

Billed customers for annual service contract to service the cathodic protection systems installed in water tanks. Billed customers for annual service contract to service the cathodic protection systems installed in water tanks.

Administrative Assistant, Medina Plant

• 1989 - 1992

Processed sales orders, performed Accounts Payable, dispatched shipping and maintained information technology system. Processed sales orders, performed Accounts Payable, dispatched shipping and maintained information technology system.